Drug Abuse and Drug Abuse and WoundsWounds

Ronald A. Kline, M.D., Ronald A. Kline, M.D., F.A.C.S., F.A.H.A.-S.C.F.A.C.S., F.A.H.A.-S.C.

Arizona Endovascular CenterArizona Endovascular Center

Chief, Division of Vascular & Chief, Division of Vascular & Endovascular Surgery, Carondelet St. Endovascular Surgery, Carondelet St.

Joseph HospitalJoseph Hospital

Medical Director Wound Care, Medical Director Wound Care, Carondelet St. Joseph Hospital and Carondelet St. Joseph Hospital and

Kindred Hospital TucsonKindred Hospital Tucson

A Legal DrugA Legal Drug

Antique SyringeAntique Syringe

Antique SyringeAntique Syringe 1670 crude forms 1670 crude forms

of IV injectionsof IV injections 1853 Charles 1853 Charles

Pravaz & Pravaz & Alexander Wood Alexander Wood simultaneously simultaneously develop modern develop modern style syringestyle syringe

United KingdomUnited Kingdom

1860 all drugs legal and used across 1860 all drugs legal and used across societysociety

Prime Minister William Gladstone & Prime Minister William Gladstone & Florence Nightingale use opiumFlorence Nightingale use opium

Queen Victoria used cannabisQueen Victoria used cannabis Sherlock Holmes (Sir Arthur Conan Sherlock Holmes (Sir Arthur Conan

Doyle) injected opium derivative Doyle) injected opium derivative during case hiatus for relaxationduring case hiatus for relaxation

PrevalencePrevalence

50% of DRH trauma patients test 50% of DRH trauma patients test positive for cocaine, heroin or bothpositive for cocaine, heroin or both

1998 estimate by National Institute of 1998 estimate by National Institute of Drub Abuse 21 million of USA have Drub Abuse 21 million of USA have tried cocaine, 3 million within last tried cocaine, 3 million within last monthmonth

Cocaine related violent deaths in Salt Cocaine related violent deaths in Salt Lake City & Tucson are risingLake City & Tucson are rising

1.8 million patients / year admitted 1.8 million patients / year admitted for treatment in the USAfor treatment in the USA

Anatomy of a Crack PipeAnatomy of a Crack Pipe

Changeable screen

Crack rocks burned here

Mouthpiece

Coolant chamber

““The Blind Eye”The Blind Eye”

Drug Abuse Warning Network Drug Abuse Warning Network (DAWN)(DAWN) Section of US Health & Human Services Section of US Health & Human Services

are under reporting to Congressare under reporting to Congress 1992 reported 5% incidence of cocaine use 1992 reported 5% incidence of cocaine use

in patients treated at Hospital of the in patients treated at Hospital of the University of PennsylvaniaUniversity of Pennsylvania

Hospital prospective internal review showed Hospital prospective internal review showed 20% of blunt trauma and 57 % penetrating 20% of blunt trauma and 57 % penetrating trauma victims tested positive for cocainetrauma victims tested positive for cocaine

MarijuanaMarijuana

Research indicates more Research indicates more carcinogens than in tobaccocarcinogens than in tobacco

Bladwin at UCLA: alveolar Bladwin at UCLA: alveolar macrophages have reduced macrophages have reduced bactericidal activity to bactericidal activity to Staph. Staph. AureousAureous

Users with depressed cytotoxic and Users with depressed cytotoxic and immunoprotective levels of immunoprotective levels of interleukin-6interleukin-6

CocaineCocaine

Alkaloid extract of Alkaloid extract of Erythroxylon Erythroxylon coca, coca, powder formpowder form

Purified by dissolving in acetone or Purified by dissolving in acetone or alcohol and smoked as “free base”alcohol and smoked as “free base”

Alkaloid dissolved in HCl acid to Alkaloid dissolved in HCl acid to form water soluble saltform water soluble salt

““Crack” is the neutral form made Crack” is the neutral form made without solvent extraction by adding without solvent extraction by adding an alkali to cocaine hydrochloridean alkali to cocaine hydrochloride

CocaineCocaine

Crack is the most common cause of MI Crack is the most common cause of MI and / or strokes in young Americansand / or strokes in young Americans

It affects arteries of all sizesIt affects arteries of all sizes Transpulmonic absorption is increased Transpulmonic absorption is increased

by a two person Valsalva’s maneuverby a two person Valsalva’s maneuver Acute mediastinal air dissectionAcute mediastinal air dissection Care is supportiveCare is supportive Transcoronary or carotid air dissectionsTranscoronary or carotid air dissections

Cocaine EffectsCocaine Effects

Dose dependentDose dependent Local anesthesiaLocal anesthesia Local vasoconstrictionLocal vasoconstriction Sympathomimetic action by blocking Sympathomimetic action by blocking

re-uptake of norepinephrine and re-uptake of norepinephrine and dopaminedopamine

Cocaine EffectsCocaine Effects

Pathophysiologic effectsPathophysiologic effects ΔΔp / p / ΔΔt = dissectionst = dissections Spasm in medium & small sized arteriesSpasm in medium & small sized arteries

GI bleedsGI bleeds Induces hypercoagulabilityInduces hypercoagulability

Platelet aggregationPlatelet aggregation Decreases protein C and anti-thrombin III Decreases protein C and anti-thrombin III

levelslevels Inhibits thrombolysisInhibits thrombolysis

Crack Induced Aortic Crack Induced Aortic DissectionDissection

14 year old after 14 year old after acute crack usageacute crack usage

Intra-aortic ThrombosisIntra-aortic Thrombosis

PCP or “Angel Dust”PCP or “Angel Dust”

Hog, squeeze, wack, space base (mixed Hog, squeeze, wack, space base (mixed with crack)with crack)

1-(1-phencyclohexyl) piperidine1-(1-phencyclohexyl) piperidine Original form mixed with heroine, now Original form mixed with heroine, now

cocainecocaine Mixing potentiates each effects and Mixing potentiates each effects and

reduces the LDreduces the LD5050

3 – 8 mg mild intoxication3 – 8 mg mild intoxication 8 – 12 mg HTN, fever, “ zombie walk”8 – 12 mg HTN, fever, “ zombie walk”

PCP or “Angel Dust”PCP or “Angel Dust”

> 12 mg profound hypotension, > 12 mg profound hypotension, coma, convulsions, muscular coma, convulsions, muscular rigidity, deathrigidity, death Effects last for daysEffects last for days Rabdomyolysis necessitates Rabdomyolysis necessitates

fasciotomiesfasciotomies Treatment is supportive Treatment is supportive

AmphetaminesAmphetamines

Methamphetamine & “Ecstasy”Methamphetamine & “Ecstasy” 3,4-methylenedioxymethamphetamine3,4-methylenedioxymethamphetamine

Inotropic and chronotropic effects Inotropic and chronotropic effects like cocainelike cocaine Strokes and aortic dissectionsStrokes and aortic dissections Chronic usage: depressionChronic usage: depression

““Meth” labsMeth” labs House buyers bewareHouse buyers beware

Other AgentsOther Agents

Anything that can be dissolved or Anything that can be dissolved or liquified has been injectedliquified has been injected Acetominaphine, codeine, TalwinAcetominaphine, codeine, Talwin®®

Incomplete dissolution or precipitation Incomplete dissolution or precipitation problematicproblematic

Inadvertent intra-arterial injectionInadvertent intra-arterial injection Common in hand and forearmCommon in hand and forearm CarotidCarotid Treatment is heparin and await for Treatment is heparin and await for

demarcationdemarcation

““Trashed” HandsTrashed” Hands

Arm FasciotomyArm Fasciotomy